What Works for Women and Girls

9B. Safe Motherhood and Preventionof Vertical Transmission: Pre-ConceptionAlthough many women don’t learn their HIV status until they become pregnant, for thosewomen who know they are HIV-positive prior to choosing to become pregnant, pre-conceptionassessments may inform both her and her partner of the safest way to become pregnantwithout HIV transmission to the infant or HIV transmission between serodiscordant couples.Therefore, throughout their reproductive years, women living with HIV need ongoing comprehensivepre-conception care that is incorporated into primary care services so they can makeinformed choices about pregnancy prior to conception.While maternal health services traditionally do not“It is also important to know yourstatus even before you becomepregnant so that you can at leastknow the ways of not letting thebaby get infected.”—Kenyan woman (Centerfor Reproductive Rights andFederation of Women Lawyers—Kenya, 2007)provide pre-conception care but rather start once a womanis pregnant with antenatal care, women with HIV canbenefit from pre-conception care. As PMTCT programs arescaled up, including pre-conception care as part of maternalhealth services should be considered.Pre-conception care should include counseling onbarrier methods of family planning to decrease transmissionof HIV and prevent secondary infection, skills tonegotiate condom use, assessment of a woman’s nutritionalstatus, education and counseling on perinatal HIVtransmission and pregnancy risks, and support and counselingfor partner disclosure on HIV status before pregnancy.Specific recommendations include for health care providers to “ask about pregnancyintentions to every woman, every visit,” and to discuss “the risks and effects of pregnancyon…[preexisting] medical condition[s], and the effects of the medical condition on pregnancyoutcomes…so that the patient can make an informed decision about becoming pregnant…Education and counseling for HIV-infected women about perinatal HIV transmission risks,strategies to reduce those risks, the potential effects of HIV or its treatment on pregnancy, andthe risk of transmission during breastfeeding, allows patients to be fully aware of the issuesconcerning HIV infection and pregnancy before conception” (Aaron and Criniti, 2007).“Because it is important for HIV-positive women receiving HAART to time their pregnanciesat a point when their CD4 cell count is high and their viral load is low, women should becounseled to use contraceptives until laboratory testing can determine that these levels areoptimal for becoming pregnant” (Sable et al., 2008). [See also Chapter 7C. Treatment: ReducingTransmission] Women should also know that studies conflict regarding an increased risk ofHIV acquisition during pregnancy (Morrison et al., 2007 and Gray et al., 2005), but that pregnancydoes not increase the risk of early death (Allen et al., 2007a). “For those with access tofertility centers, longitudinal data show that conception can occur with a very low risk of HIVtransmission… While the experience with assisted reproductive health technologies is encour-WHAT WORKS FOR WOMEN AND GIRLS215